Correspondence Address:
Ruchi Kumari
Department of Anesthesiology and Critical Care, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi – 110 002
India

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The Editor,

Difficult intravenous placements happen to every medical practitioner, but when performed by an experienced one, it can appear deceptively easy. In fact, it is a highly technical skill that requires a lot of knowledge, as well as considerable practice. Peripheral intravenous cannulation allows to access the circulation, to sample blood, and infuse fluids and medications. The ability to obtain intravenous access through cannulation of a peripheral vein is an essential skill in medicine and in anesthesiology, in particular. Intravenous cannulation may be difficult in patients with extremes of age, obesity, hypotensive, intravenous drug abusers, or patients with multiple injuries limiting the limbs available for cannulation.[1] Moreover, the patients shifted to the operating room are already fasted, dehydrated, frightened, and have a very high sympathetic outflow. Furthermore, the operating room can be cold, and all these factors together result in a significant diminution of peripheral veins.

There are several different methods to facilitate intravenous cannula placement in difficult patients, such as illumination or ultrasound, application of a Bair Hugger, forced-air warming devices, or application of warm compresses.[2] Although USG is a great tool for bigger veins, it is not so for superficial peripheral veins. Furthermore, the warming techniques take a lot of time that further delays the surgery.

To increase the size and visibility of peripheral veins, a tourniquet can be used. The idea is that one should be able to apply the compression around the arm or leg so that the arterial inflow continues, but the venous outflow is prevented. Thus, it causes engorgement of the peripheral vein.

One better way to apply a tourniquet is to apply a BP cuff and set it at 90 mmHg, or slightly below the DBP, which makes the vein enlarged and visible.

Another lesser-known technique for difficult intravenous cannulation is the Reverse Esmarch technique. In this technique, a highly elastic rubber bandage, that is, Esmarch bandage, is applied at the proximal aspect of the limb and slowly moved toward the peripheral aspect of the extremity while squeezing the blood consistently toward the distal extremity by “stretch and apply” technique until one gets toward the distal extremity, that is, in a “reverse fashion” from proximal to distal. This technique causes the pooling of blood distally in the hand and engorgement of veins.[3] And, then the peripheral vein is assessed by tapping on the skin which causes vasodilatation due to the release of inflammatory mediators. That is how the vein which was previously invisible becomes visible.

Moreover, Esmarch bandage has also been successful in identifying the superficial veins in patients with edema of the extremities. It causes shunting of edema distally to proximally and makes peripheral veins more visible when applied in a distal to proximal fashion.[4]

It should be noted that the Esmarch bandage should not be applied when limb trauma is evident, and also it should not be left in place for more than 5 min as it makes the vein more tortuous and fragile.[1],[5]

This lesser-known and inexpensive technique may prove useful during difficult intravenous cannulation.

Acknowledgments

Dr. Ruchi Kumari, MD Anesthesiology and Critical Care, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References